In situ implantation of a prosthetic systemic atrioventricular valve in corrected transposition.
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Child, Preschool↗
Biomedical subjects
A Elami
Publications and source records attributed to A Elami.
Systolic pressure variation predicts the response to acute blood loss.
STUDY OBJECTIVE: To evaluate systolic pressure variation (SPV), defined as the difference between the maximum and minimum systolic blood pressure measured during a controlled mechanical respiratory cycle, as a predictor of the cardiac output (CO) response to an acute decrease in ventricular preload. DESIGN: Prospective study with each subject serving as his or her own control. SETTING: Cardiac surgery operating rooms of a university medical center. PATIENTS: 15 adults with good ventricular function undergoing coronary artery bypass grafting. INTERVENTION: During stable anesthetic conditions and before surgical stimulation, 500 ml of blood was removed from each patient over 10 minutes. MEASUREMENTS AND MAIN RESULTS: CO, central venous pressure (CVP), pulmonary artery diastolic pressure, and pulmonary artery occlusion pressure (PAOP), and SPV before and after phlebotomy were recorded. Phlebotomy was associated with significant decreases in CVP, PAOP, and CO, and an increase in SPV. Of these variables, SPV was the best predictor of the percent decrease in CO resulting from blood loss. CONCLUSION: SPV is a dynamic measurement, which, by revealing the response to small cyclical changes in left ventricular preload that occur during the controlled mechanical respiratory cycle, is a better predictor than central filling pressures of the response of CO to acute decreases in preload that occur as a result of acute blood loss.
Acute Disease↗
Sudden hemorrhagic tamponade simulating subacute ventricular rupture after acute myocardial infarction.
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Cardiac Tamponade↗
Endogenous basic fibroblast growth factor displaced by heparin from the lumenal surface of human blood vessels is preferentially sequestered by injured regions of the vessel wall.
BACKGROUND: Proliferation of smooth muscle cells (SMCs) of the arterial wall in response to local injury is an important factor in vascular proliferative disorders. Among the growth factors that promote SMC proliferation is basic fibroblast growth factor (bFGF), which is characterized by a high affinity for heparin and is associated with heparan sulfate on cell surfaces and extracellular matrices. We investigated whether heparin can displace endogenous active bFGF from the lumenal surface of blood vessels, whether bFGF is preferentially bound to injured blood vessels, and whether a synthetic, polyanionic, heparin-mimicking compound (RG-13577) can prevent sequestration of bFGF by the vessel wall. METHODS AND RESULTS: Injured and noninjured saphenous vein segments were perfused with or without heparin, in the absence or presence of 125I-bFGF and/or RG-13577 (a polymer of 4-hydroxyphenoxy acetic acid). Heparin displaced bFGF from the lumenal surface of the vein, and the released bFGF stimulated proliferation of SMCs. Likewise, systemic administration of heparin during open heart surgery resulted in a marked increase in plasma bFGF levels. Injured veins sequestered 125I-bFGF to a much higher extent than noninjured vein segments, both in the absence and presence of heparin. This sequestration was inhibited by compound RG-13577. CONCLUSIONS: Despite its beneficial effects, heparin may displace active bFGF, which subsequently may be preferentially deposited on injured vessel walls, thus contributing to the pathogenesis of restenosis. This effect may be prevented by a synthetic heparin-mimicking compound.
3T3 Cells↗
Cerebral protection using retrograde cerebral perfusion during hypothermic circulatory arrest.
BACKGROUND: Retrograde cerebral perfusion through the superior vena cava (SVC) has been proposed to protect the brain from ischaemic injury during profound hypothermic circulatory arrest (PHCA). Its contribution to cerebral protection is unclear. Furthermore, the addition of anaesthetic or vasodilating agents to the SVC perfusate to enhance brain protection, has never been described. METHODS: In three patients undergoing repair of the ascending aorta utilizing PHCA, the upper body was retrogradely perfused with cold (16 degrees C) blood through the SVC by the cardiopulmonary bypass pump. Electroencephalographic activity was monitored using a computerized electroencephalographic monitor (Cerebro Trac 2500, SRD). Perfusion pressure was measured at a port in the cannula connector. Etomidate or thiopentone was injected into the SVC perfusate to arrest reappearing electroencephalographic activity. Nitroglycerin or nitroprusside was injected into the perfusate to increase retrograde flow and maintain a constant perfusion pressure. RESULTS: During PHCA periods of up to 61 min, recurrent electroencephalographic activity was abolished by the retrograde administration of small boluses of etomidate (total 50 mg) or thiopentone (total 500 mg). Nitroprusside (100 micrograms) and nitroglycerin (2 micrograms.kg-1.min-1) increased retrograde flow from 220 to 550 and 660 ml.min-1, respectively, while maintaining perfusion pressure (25-26 mmHg). Recovery from anaesthesia and surgery was uneventful, with no adverse neurological sequelae. CONCLUSION: Injection of anaesthetic agents into the retrograde SVC perfusate during PHCA, can suppress reoccurring electroencephalographic activity and retrograde injection of vasodilators can facilitate an increase in perfusion. It is suggested that both may augment brain protection.
Aged↗
Microbiological cultures of heart valves and valve tags are not valuable for patients without infective endocarditis who are undergoing valve replacement.
We evaluated the significance of the results of microbiological cultures of heart valves and identification tags from newly inserted prosthetic valves that were removed from patients with valvular heart disease; none of these patients had a preoperative diagnosis of endocarditis. We reviewed the charts of patients with positive cultures for evidence of infections before or after surgery. Cultures were positive for 11.9% of 219 valves (206 native valves and 13 prosthetic or bioprosthetic valves) and 11.6% of 224 tags. The most common isolates were coagulase-negative staphylococci. Typical agents of endocarditis--viridans streptococcus, Enterococcus faecalis, and Staphylococcus aureus--were cultured from five specimens, and Mycobacterium avium complex was identified in six valves. None of the patients with positive valve or tag cultures developed postsurgical endocarditis or wound infection. Findings on histopathologic examination of the valves were not consistent with endocarditis. We conclude that the results of cultures of valves from patients without preoperative diagnoses of endocarditis lack clinical significance, and positive tag cultures are not predictive of postsurgical infection. Positive cultures are most likely a result of contamination during surgery or thereafter.
Adolescent↗
Halothane prevents postischemic production of hydroxyl radicals in the canine heart.
BACKGROUND: Recent studies indicate that during regional myocardial ischemia and subsequent reperfusion, volatile anesthetics may provide protection against free radical-related injury. The effect of halothane on free radical production during ischemia and reperfusion, in the canine heart, was investigated. The level of hydroxyl radical (.OH)-mediated conversion of salicylate to its dehydroxybenzoate derivatives (2,3-DHBA and 2,5-DHBA) was monitored. METHODS: Under general anesthesia, the heart was exposed through median sternotomy. Salicylate (100 mg/kg given intravenously) was administered 30 min before left anterior descending artery occlusion. Six dogs were studied using inhaled halothane (1.6%) 10 min before and during the 10-min ischemic period, followed by 50 min of reperfusion, and then they were compared with seven other dogs used as controls. Blood concentrations of salicylate, 2,3-DHBA and 2,5-DHBA, K+, lactate, oxygen content, and pH were monitored. RESULTS: An acute increase in the normalized concentrations of 2,3-DHBA and 2,5-DHBA was observed in the control animals during reperfusion. In contrast, halothane inhalation completely inhibited the production of both metabolites (P < 0.02), but 2,5-DHBA concentrations in the halothane-treated group were even less than the basal level (P < 0.05). The increase in lactate concentrations in the experimental animals was significantly less than that of controls (P < 0.05) and followed the same time-dependent pattern as the changes in K+ and pH. Halothane significantly decreased (P < 0.0001) the difference in oxygen content between coronary sinus and aortic root blood, suggesting decreased oxygen utilization during reperfusion. CONCLUSIONS: Halothane completely inhibited the production of .OH, and its administration may protect the heart from the deleterious effect of oxygen-derived reactive species, with attenuation of the metabolic response to ischemia.
Anesthetics, Inhalation↗
Positive end-expiratory pressure increases pulmonary venous vascular resistance in patients after coronary artery surgery.
OBJECTIVE: To investigate the effect of positive and-expiratory pressure (PEEP) on the longitudinal distribution of pulmonary vascular resistance in patients immediately after coronary artery bypass grafting. DESIGN: Prospective, intervention study. SETTING: Postcardiac surgery intensive care unit in a teaching institution. PATIENTS: Twenty patients after elective coronary artery bypass grafting. INTERVENTION: The effect of PEEP on pulmonary circulation, at four different levels (0, 5, 10, and 15 cm H2O), was analyzed in 20 patients. MEASUREMENTS AND MAIN RESULTS: Mean pulmonary arterial pressure, left atrial pressure, pulmonary artery occlusion pressure, and pulmonary capillary pressure were measured at each PEEP level. A model consisting of two resistances in series was used to analyze the effect of PEEP on the pulmonary circulation. The pulmonary vascular resistance for each area (arterial and venous) of the circulation was calculated. Pulmonary vascular resistance increased from 216 +/- 70 dyne.sec/cm5 at a PEEP of 0 cm H2O to 308 +/- 125 dyne.sec/cm5 at a PEEP of 15 cm H2O (p < .001). This increase, however, resulted solely from an increase in the resistance of the venous part of the pulmonary circulation from 66 +/- 29 to 134 +/- 69 dyne.sec/cm5 (p < .001), without any change in pulmonary arterial resistance. CONCLUSIONS: PEEP increases pulmonary vascular resistance solely by increasing pulmonary venous resistance. When applying PEEP, changes in pulmonary vascular resistance may impede the resorption of pulmonary edema fluid.
Aged↗
Single pass lead VDD pacing in children and adolescents.
Implantation of permanent pacemakers in children and adolescents is possible but usually is limited to single chamber generators. The natural growth of these patients may require physiological pacing, but until recently two leads were required for this type of pacing. The single pass lead VDD pacing mode makes possible physiological pacing by using only one lead, for both atrial sensing and ventricular sensing and pacing. The feasibility of VDD pacing using endocardial lead was evaluated in 16 children and adolescents with congenital or postsurgical atrioventricular block. Their mean age was 7.9 +/- 4.9 years (range 1-16 years) and the smallest patient's weight was 8.2 kg. In all the patients, a single pass pacing lead with atrial sensing rings and bipolar ventricular pacing and sensing capability was implanted through the left or right subclavian vein. The pacemaker generator was implanted in a rectopectoral position. The mean atrial electrogram during the implantation was 4.2 +/- 2.1 mV and 2.6 +/- 1.9 mV after a mean of 1 week. The ventricular pacing threshold was 0.5 +/- 0.2 V; the ventricular pacing impedance was 560 +/- 95 omega; and the ventricular electrogram amplitude was 9.9 +/- 2.1 mV. This is a first report to demonstrate the feasibility of atrial synchronous ventricular endocardial pacing using a single pass lead in a relatively large group of children and adolescents.
Adolescent↗
Autologous monocusp pulmonary valve: preliminary results.
BACKGROUND: There is growing recognition that postoperative pulmonary regurgitation may result in early or late progressive right heart failure. METHOD: A technique for fashioning an autologous monocusp pulmonary valve from the wall of the pulmonary artery was developed. The monocusp valve was fashioned from the anterior wall of the main pulmonary artery, and the remaining defect was filled with autologous pericardium. The procedure was performed in 8 dogs and 5 children. RESULTS: Early follow-up and serial echocardiographic assessment in both dogs and children proved the functionality of this monocusp pulmonary valve. All valves were pliable and demonstrated mild to moderate pulmonary stenosis and insufficiency. CONCLUSIONS: Construction of the autologous monocusp pulmonary valve is a feasible technique, and the valve performs efficiently. The acute performance in the canine model was excellent, and preliminary midterm results in the clinical study are reasonable. It is logical to assume that the monocusp, being an integral part of the arterial wall, will retain its viability and share in the subsequent growth of the pulmonary artery. Should follow-up studies demonstrate its long-term competence, this autologous valve may provide a good solution for various forms of pulmonary regurgitation and be useful in pulmonary autograft replacement of the aortic valve.
Animals↗
Early experience in lung transplantation.
Lung transplantation is becoming an acceptable mode of therapy worldwide for the end-stage lung disease. We present our initial experience with the first 10 consecutive lung transplant patients at Hadassah University Hospital. There were 5 males and 5 females with an age range 27 to 59 years. Eight patients underwent single lung transplantation, one patient had double lung transplantation and one had heart-lung transplantation. Indications were: pulmonary fibrosis in 4, emphysema in 4, cystic fibrosis in 1, and cystic bronchiectasis in 1. Two patients had primary graft failure (1 death). Nine patients had a serious infection after transplantation (1 death). Four patients developed airway complications including dehiscence of bronchial anastomosis (1 death), bronchial stenosis requiring placement of a stent in 2 patients, and pneumothorax in 1 patient. One patient required tracheostomy. One patient died of massive brain infarction secondary to pulmonary venous thrombosis and embolization. Six patients are intermediate-term survivors, with a follow-up period of 4-24 months. Four of them had at least one episode of rejection each. In all survivors pulmonary functions and quality of life improved and they do not need supplemental oxygen. We conclude that lung transplantation is a viable option for end-stage lung disease. Better selection of patients and perhaps improved immunosuppression agents will further improve outcome in lung transplantation. Shortage of donor supply is currently the limiting factor in successful lung transplantation in Israel.
Adult↗
[Aortopulmonary window: influence of associated cardiovascular lesions on surgical management].
Aortopulmonary (AP) window is an uncommon cardiac anomaly which is frequently associated with other cardiac anomalies. Concomitant repair of all intra- and extracardiac anomalies is usually recommended. Between October 1993 and July 1994, 4 patients aged 37 days, 4 weeks, 3.5 and 1.5 years, respectively, underwent repair of AP window and associated malformations. The associated anomalies consisted of interrupted aortic arch (IAA), and atrial and ventricular septal defects in the 1st patient, patent ductus arteriosus in the 2nd, inlet ventricular septal defect in the 3rd and congenital narrowing of the right pulmonary artery and a patent foramen ovale in the 4th. Extreme metabolic acidosis after repair of IAA in the 1st, dictated ligation of the AP window before repair of the intracardiac anomalies at 2 months of age. In the 2nd and 3rd, repair of the window and associated anomalies was performed in a single stage. In the 4th, left pulmonary artery banding preceded complete repair. All patients are doing well at 18, 13, 12 and 11 months, respectively, of follow-up after their last operation. Surgical management of AP window may have to be staged according to the physiological influence of the associated anomalies in each patient, to minimize the cumulative risk of complete repair.
Abnormalities, Multiple↗
[Treatment of concomitant coronary and carotid disease].
The optimal surgical treatment for concomitant carotid and coronary artery disease is controversial. Between 1991 and 1995 we performed 34 procedures for combined disease of the carotid and coronary arteries. The first 8 operations were carotid endarterectomies followed by coronary artery bypass grafting (staged procedure). The next 26 operations were performed during a single anesthesia (combined procedure). The patients were 28 men and 6 women, aged 58-81 years (mean 68). 80% were in functional class III or IV. In 40% ventricular function was moderately or severely reduced. There was an average of 3.6 grafts per patient, and in all except 3 patients the left internal thoracic artery was used as a conduit for coronary artery bypass grafting. 30% had symptomatic carotid stenosis; there was no perioperative mortality. In the staged procedure group, 2 patients had postoperative cardiac complications: in 1 acute coronary insufficiency and acute myocardial infarction in the other. 1 had postoperative, transient, amaurosis fugax. In the combined procedure group, 1 had a myocardial infarction and 1 a minor occipital stroke. During follow-up, 1 patient died 4 months after operation of myocardial infarction, and 1 had a minor stroke. The results suggest that the combined procedure is safe and carries low risk of both mortality and morbidity. Whenever cardiac disease is stable and there is no main coronary artery disease, a staged procedure should be considered. In any other situation we continue to perform the combined procedure.
Aged↗
Tetralogy of Fallot, absent pulmonary valve, partial anomalous pulmonary venous return and coarctation of the aorta.
We describe a unique combination of tetralogy of Fallot, absent pulmonary valve, aortic coarctation with partial anomalous pulmonary venous connection and a retroaortic innominate vein. Surgical repair was successfully accomplished in two stages: coarctation repair preceded correction of the intracardiac anomalies.
Aortic Coarctation↗
Intraoperative detection of unsuspected distal coronary obstruction by thermal coronary angiography.
Intraoperative assessment of graft patency and completeness of revascularization can increase the success of coronary artery bypass grafting. A 56-year-old man underwent a quadruple bypass operation. Flow in the graft to the anterior descending artery was verified after completion of the distal anastomosis using a Doppler flow detector. Visualization of the native artery by thermal coronary angiography demonstrated that the flow passed into the second diagonal branch and not into the distal anterior descending artery, which had an unsuspected obstruction just distal to the anastomosis. The obstruction was dilated. Patency was verified with cold solution, and flow of warm blood to the entire artery was accomplished. This case demonstrates how the early (intraoperative) recognition of an unsuspected coronary obstruction using an infrared imaging system can improve the results of myocardial revascularization and avoid potential postoperative complications.
Coronary Angiography↗
Usefulness of late potentials on the immediate postoperative signal-averaged electrocardiogram in predicting ventricular tachyarrhythmias early after isolated coronary artery bypass grafting.
The present study was undertaken to determine the value of abnormal late ventricular potentials on signal-averaged electrocardiograms (ECG) in identifying patients at risk of developing ventricular tachycardia or ventricular fibrillation in the early postoperative period after coronary artery bypass grafting. Signal-averaged ECGs were recorded immediately after operation in 72 patients. Abnormal late potentials were defined as the presence of 2 or 3 of the following: (1) root-mean-square amplitude of the last 40 ms of the QRS < 20 microV; (2) duration of the terminal QRS potentials (after 40 microV) > or = 39 ms; and (3) high-frequency QRS duration > 120 ms (in patients with conduction defects, only the first 2 criteria were used). Abnormal late ventricular potentials were present on the immediate postoperative signal-averaged ECG in 26 of the 72 patients (36%). Life-threatening ventricular tachyarrhythmias occurred in 6 patients. Late potentials were present in all 6 patients, but only in 20 of 66 (30%) who did not develop ventricular tachyarrhythmias (p < 0.005) (sensitivity 100%, specificity 70%, predictive accuracy 72%). Of 12 pre- and perioperative variables examined by univariate and multivariate regression analysis, the presence of late potentials on the signal-averaged ECG and low cardiac output postoperatively were found to be independent predictors of life-threatening tachyarrhythmias.
Action Potentials↗
Open heart operation after pneumonectomy.
A coronary artery bypass operation was performed successfully on a 70-year-old patient who had undergone left pneumonectomy 40 years earlier. This case, together with a search of the literature and a mail survey among 118 cardiothoracic surgeons worldwide, yielded data on 27 such patients for review. Two patients died perioperatively. Three patients had pneumothorax, and 1 patient had recurrent pleural effusion. Difficulty in exposing the circumflex marginal branches was reported in 2 patients after left pneumonectomy. We conclude that with attention to the specific features of the preoperative, intraoperative, and postoperative management, open heart procedures can be performed on patients after pneumonectomy with acceptable operative mortality and morbidity.
Aged↗
Truncal valve repair: initial experience with infants and children.
The truncal valve regurgitation that frequently arises in patients with truncus arteriosus accounts for increased operative and late mortality. Five patients underwent truncal valve repair at UCLA Medical Center between August 1990 and September 1991. This group consisted of 2 infants who underwent complete repair and 3 who underwent valve repair together with right ventricle-pulmonary artery conduit replacement. The techniques used for repair were individualized according to the specific valve morphology, and consisted of the suturing of partially developed commissures, suspension of the cusps, resection of redundant portions of the cusps, annuloplasty at the commissures, and resection of excrescences on the surface of valve leaflets. In 1 infant who had a severely dysplastic truncal valve, stenosis and regurgitation recurred and progressed, and he died 4 months after truncal valve replacement. The remaining 4 patients, who were followed for from 8 to 21 months after repair, are in New York Heart Association class I, and have minimal or no aortic regurgitation. Except in patients with severely deformed and dysplastic valves, truncal valve repair can be an attractive and successful alternative to valve replacement.
Child↗